Anuraag Srivastava
Proper insurance verification ensures timely payments and reduced claim denials. A simplified look at an accurate insurance verification process can help prevent financial losses and operational inefficiencies. Here’s a step by step look at the steps involved in the insurance verification process:
Step 1: Collection of Patient Information
The first step in any insurance verification process is critical. It begins with gathering accurate and comprehensive patient information. This includes their full name, date of birth, address, contact details, insurance provider details, policy number and group number. It is possible that employer details and the patient’s social security number may be asked in some cases.
Accuracy is essential too. This is true for the initial patient information gathering process as it should be error-free. If errors are detected, it can eventually lead to incorrect verification and issues in billing processes. Verifying the information at the time of scheduling an appointment can help overcome the risks associated with failure in the initial step.
Healthcare providers should implement standardized intake forms to collect all the necessary information, without fail to ease this process. Digital solutions can be utilized as well, such as online patient portals can be used to enable the self-registration process. This will potentially reduce errors and administrative workload.
Step 2: Contacting the Insurance Provider
Once step 1 is achieved successfully and patient information is collected, the next step involves reaching out to insurance providers to verify coverage details. This can be done in multiple ways. One way is through online verification portals, which have made the process more efficient, by allowing providers to access real-time eligibility information.
Another way is through speaking directly with an insurance representative, which is usually the case in complex cases. It is recommended that providers maintain an updated contact list of major insurance providers.
Verification requests should be initiated 48 to 72 hours before the scheduled services and using real-time eligibility verification tools can significantly reduce manual efforts and simplify the process.
Step 3: Confirmation of Coverage Details
The next step is critical too. It is important to confirm the specific details of the patient’s insurance coverage during verification. The team must make sure that the policy is active and then determine what type of services are covered under the plan. Some elements that should be checked include co-payments, deductibles and coverage limitations.
Some treatment might also require pre-authorization from the insurance provider. If these requirements are not met, the claim could be denied. This could lead to unexpected costs for both the patient and the healthcare provider.
Documenting all the coverage details carefully is important to avoid any discrepancies. Thus, it is also essential that the name of the insurance representative handling the verification is recorded, and written confirmation of benefits is requested, wherever possible.
Cross-checking the current coverage information with previous verifications can help identify any consistencies that are an obstacle to services being provided.
Step 4: Verifying Secondary Insurance Coverage
Sometimes, there are certain costs not included in primary coverage. In these cases, patients might utilize secondary coverage. Providers should understand coordination of benefits (COB) across both the plans to know which insurance is responsible for primary coverage and which one corresponds to secondary coverage.
The verification process should thus include checking for secondary coverage and determining patient responsibility after both the insurances have been accounted for. Providers should check if the patient has secondary coverage at the onset of the insurance verification process to ensure there are no administrative or billing errors.
Step 5: Managing Referral and Pre-Authorization Process
There are two other scenarios. One, certain medical procedures require pre-authorization from the insurance providers. Providers should typically maintain a list of procedures that might require pre-authorization. They should begin the authorization process well in advance of the scheduled date of service.
Secondly, certain procedures might require a referral from the primary care physician. This requirement must be checked before rendering the service to avoid claim denials. Thus, keeping a record of authorizations and approval documents is essential for tracking purpose and reference.
Failure to secure approval might increase financial burden on both provider and patient, thus compliance with insurance requirements is crucial.
Step 6: Communicating Verification Results to Patients
It is the healthcare provider’s responsibility to communicate the findings to the patient once the verification process is complete. Patients should be informed of their insurance coverage details, which should include co-payments, deductibles, non-covered services, and any pre-approvals of referrals.
There are certain advantages to clear communication. Firstly, patients are able to better understand their financial responsibilities. This prevents unexpected bills. Secondly, patients should be provided with a written breakdown of their coverage and the associated charges.
Financial counseling services can also be offered to assist patients in understanding their payment responsibilities. This would make the billing process smoother and more predictable.
Step 7: Documentation of Verification Information
Proper documentation of the verified information is essential for operationally efficient processes. By using electronic health records (EHR) or practice management systems (PMS) to store data securely, healthcare practitioners can ensure compliance with the regulations.
It is also helpful to train staff on HIPAA compliance and secure data handling practices to ensure that the sensitive information is always protected. Ensuring that documentation is always updated is essential for accurate recordkeeping and preventing issues arising from outdated insurance details.
PCH Health: Insurance Verification Services
PCH Health can be your partner in enhancing efficiency of your insurance verification process. We have over 30 years of experience in the Electronic Health Record (EHR) management, and we have developed robust payer relationships and customizable eligibility services to meet the needs of healthcare providers.
Our dedicated insurance eligibility and benefits verification team works diligently to maximize revenue, and ensure timely and accurate insurance coverage processing. By integrating PCH Health's solutions, providers can reduce claim denials, optimize collections, and improve patient satisfaction through streamlined operations and reduced billing errors. Request a demo to learn more.